Client Medical Clearance Form Page 2
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22. Medications
Is the patient currently or recently (within the last 12 months) taking / taken:
a) Blood pressure medication
YES
NO
b) Diuretics
YES
NO
c) Cardiac medications
YES
NO
d) Gout medication
YES
NO
e) Arthritis / anti-inflammatory
YES
NO
f) Asthma medication
YES
NO
g) Other medication
YES
NO
If YES, please indicate the following
Medication Name
Reason for
Dosage
Duration on
Possible relevant side
Medication
medication
effects
Medical Clearance
____ I feel that there are NO medical contra-indications to my patient undergoing a
graduated exercise program.
____ I feel that my patient is NOT able to participate in a graduated exercise program for the
following reasons: ________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Medical Practitioner’s Signature: _______________________________
Date: ____/____/____
Medical Practitioner’s Name: __________________________________
Address: ______________________________________________________________________
Telephone: (_____) __________________________
Websites/ Personal Best/ Downloads/ Client Documents/ Client Medical Clearance Letter
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Parent category: Medical